Patient safety advocates recognize the lack of appropriate measures to track improvements, and the debate continues regarding what metrics can fulfill this role. Building on results of a recent study of hospitals in the Netherlands, this commentary discusses the degree to which the nonsignificant reduction in preventable adverse events may actually signify real improvements. The authors also suggest that the study findings highlight some of the limitations of adverse events as a measure of progress in patient safety.

Book/Report

To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.

Journal Article > Review

Researchers searched the term "patient safety" in the nursing literature and found that few articles gave clear explanations of the concept. Using case discussions to illustrate patient safety in practice situations, the authors seek to help nurses understand the concept, empower them to engage in multidisciplinary efforts to improve safety in care environments, and promote measurement of patient safety data.

Journal Article > Commentary

Patient safety concepts in medical education are lacking. Discussing the value of teaching medical students to identify and address safety hazards, this commentary calls for faculty to not only provide training for these competencies but personally exhibit safe behaviors and practice.

This pre-post study evaluated the impact of smart pump infusion devices on reported adverse drug events (ADEs) in an inpatient setting. Researchers observed an increase in ADEs immediately following implementation of the new devices, as has been previously seen after electronic health record implementation. Subsequently, ADEs returned to rates similar to before smart pump use. This lack of benefit from smart pumps indicates the need for human factors approaches to characterize the actual use of devices.

Journal Article > Commentary

Checklists, while popularly considered to address safety issues, can be difficult to use reliably. Spotlighting the complexities around designing and implementing checklists to augment health care safety, this commentary relates the differences between medical and aviation checklists to underscore the need to consider sociocultural elements to ensure the success of this safety intervention.

Journal Article > Study

In this study, participants observed two video-recorded scenarios of a surgeon apologizing for an adverse event. Although apologies that focused on admissions of responsibility, expressions of regret, and offers of restitution were viewed positively, those that also explicitly accounted for the patient's perspective by understanding the impact on the patient and offering to address the harm in a meaningful manner were better received.

Journal Article > Study

This qualitative study examined mechanisms by which hospital boards could provide more effective oversight of quality and safety activities. Trust among organizational leadership and prioritization of data analysis emerged as important methods by which boards could help improve safety.

Parenteral nutrition has the potential to result in patient harm if administered or prepared incorrectly. This commentary builds on a set of overarching recommendations to define competencies that enable the safe prescribing and delivery of parenteral nutrition. The model is designed to help organizations apply the suggestions in their particular care environments.

Journal Article > Commentary

Checklists have been highlighted as useful tools for nurses and physicians to improve communication and reduce care omissions. This commentary describes the development of a customizable checklist template designed to enable patients to engage in their care and safety.

Journal Article > Commentary

To illustrate the potential for harm associated with overuse of medical care, this commentary describes an incident involving a patient who received unnecessary diagnostic imaging which resulted in iatrogenic harm. A previous AHRQ WebM&M perspective explored medical care overuse as a patient safety problem.

Journal Article > Commentary

There is a recognized need for patient safety content in medical school curricula. This commentary describes the development, implementation, and evaluation of a program that integrated quality and safety improvement concepts into an existing 3-year curriculum. A patient safety expert worked with faculty to recommend the content and goals of the pathway. Students reported positive reactions to the program.

Every day the care of hospital patients is handed off from clinician to clinician, creating serious risks for patient safety. A comprehensive quality improvement program that standardized communication processes and introduced basic electronic health record messaging enhanced the rate of postdischarge verbal handoffs to primary care providers.

This cross-sectional study at three London hospitals evaluated factors related to surgical ward patients' willingness to call for help. Although patients were more likely to call a nurse for help, they were more willing to ask for help if encouraged to do so by a doctor rather than a nurse.

Significant progress has been made in preventing errors at the time of handoffs between clinicians. As demonstrated in the landmark I-PASS study, patient safety can be improved by implementation of a standard format for verbal handoffs. This study—performed by the I-PASS study investigators—examined the quality of written signout documents, which are used by overnight covering physicians to complement the verbal signout. Written signouts were not standardized in either structure or content, and they frequently lacked information elements (such as illness severity) that are considered essential for a high-quality signout. Based on these findings, the authors make recommendations for the core data elements for written signouts. A case of a delayed diagnosis due to inadequate signout is discussed in a previous AHRQ WebM&M commentary.

Journal Article > Review

Barcode technology has been advocated as a strategy to reduce medication errors. This narrative review explored barcoding solutions applied in various care settings and found that they resulted in notable reductions of transcription, dispensing, and administration errors. The authors recommend standards for successful implementation of barcode technology systems.

Applying the Leapfrog computerized provider order entry evaluation tool to four hospitals in South Korea exposed many opportunities for improvement. Although initially there was concern that national differences in drug prescription patterns might make the tool, which was developed for practices in the United States, unreliable, researchers found sufficient overlap to successfully complete the evaluation.

Book/Report

Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk of error during their primary care visit, hospitalization, communications with providers, and discharge. A past AHRQ WebM&M perspective highlighted the importance of involving patients in safety.

Journal Article > Commentary

Concerns have been raised about the variability of measures used to rate safety and quality in hospitals. Spotlighting the growing focus on publicly available quality data, this commentary provides information about the science of quality measurement, including the differences between rating systems and the strengths and weaknesses of numerical data versus survey responses.